CHAPTER 4 SALUTOGENIC FUNCTIONING

Transcription

1 107 CHAPTER 4 SALUTOGENIC FUNCTIONING With reference to chapter 1, section 1.7.1, the aim of this chapter is to conceptualise and integrate the existing literature on salutogenic functioning. In this chapter, a history of the salutogenic paradigm will first be presented, followed by a discussion of the definition and model of salutogenesis. Thereafter the selection and discussion of salutogenic constructs to be used in the study will be presented. This will be followed by a discussion of coping theory, which includes a discussion of the definition, models and dynamics of coping. In the discussion on coping, salutogenic constructs will be discussed in terms of how they act as coping mechanisms in stress and burnout. This chapter will conclude with an integration of the theoretical aspects as discussed in chapters 2, 3 and 4; including an assessment of whether salutogenic personality constructs have the ability to differentiate between copers and noncopers. 4.1 HISTORY OF THE SALUTOGENIC PARADIGM The term salutogenesis (from Latin: salus = health, Greek: genesis = origin) was coined by Antonovsky (1979). This paradigm became well known in the publication, Health, stress and coping, where Antonovsky (1987a, p. 47) advances that at any time at least one third of the world s population of any industrial society is characterised by some morbid pathological condition and illness, and that this is not a rare deviance but a normal state of the human condition. He argues that given the ubiquity of pathogens microbiological, chemical, physical, psychological, social and cultural everyone should succumb to this bombardment and should constantly be dying. However, Antonovsky (1979) noticed that this clearly was not the case, since many individuals survive and even flourish under these difficult circumstances.

2 108 Salutogenesis started as a paradigm developed from a number of independent yet related constructs, such as sense of coherence concept (Antonovsky, 1979), potency (Ben-Sira, 1985), hardiness (Kobasa, 1982), learned resourcefulness (Rosenbaum s, 1980), locus of control (Rotter, 1975) and stamina (Thomas, 1981). The reason for the conceptualisation of salutogenesis from concept to paradigm was to counterbalance the pathogenic orientation (Kraft et al, 1993; Schröder et al, 1993). Salutogenic thinking has challenged the traditional pathogenic orientation which still dominates medical research (Johnsen, 1992). Pathogenesis, as a paradigm, is concerned with the origin of disease, while salutogenesis focuses on the unravelling of the mystery of health and is an attempt to address how people manage stress and stay well (Strümpfer, 1995). Salutogenesis recognises that stressors are endemic in our lives and that there is a need to manage this stress and tension. It rejects the commonly held assumption that stressors are inherently bad, in favour of the possibility that stressors may have salutory consequences. Thus, the salutogenic question is concerned with how individual s learn to live and live well with stressors, and possibly even turn their existence to their advantage. In contrast, the pathogenic orientation is concerned with how individuals can eradicate stressors from their life (Anotonovsky, 1984 in Strümpfer, 1996, p. 267). Another important difference between the two paradigms, is that in the pathogenic orientation, the individual is either sick or well; and in the case of the salutogenesis, the individual is not categorised as being either diseased or nondiseased. Rather, individual functioning may be plotted anywhere along the line from one pole of ease to the other pole of disease (Antonovsky, 1982, p. 37). The focus of concern in the salutogenesis becomes the ease/dis-ease continuum, rather than the health-disease dichotomy. In this regard, Antonovsky (1987b) introduced the concept of generalised resistance resources (GRRs). GRRs are generalised factors relevant to all diseases, which attempt to explain what facilitates our movement towards the most salutary end of the breakdown continuum when searching for specific, disease-relevant factors. According to Kraft et al (1993, in Schröeder, 1993, p. 339), this shift from the pathogenic stress research to the salutogenic resources research has also changed the

3 109 understanding of health. According to these theorists, two issues become pertinent in the new conceptualisation of health: Cognitive processes and coping strategies are now incorporated in the understanding of health. Exchange processes between the person and the environment are responsible for the maintenance and restoration of an organismic state of balance. An important clarification in the salutogenic understanding of health is that it is possible for individuals to take responsibility for their health, provided that their environment enables them to act autonomously and to cope with health impairing stressors (Antonovsky, 1982). 4.2 DEFINITION OF SALUTOGENESIS Salutogenesis emphasises health promotion and disease prevention rather than the pathogenic origins of disease (Wolf & Ratner, 1999, p. 183). Antonovsky s (1987b, p. 7) famous question; Whence the strength? characterises the key to salutogenic thinking and has since inspired much research into why some cope successfully in spite of omnipresent stressors and others do not. From this query, salutogenesis has become associated with man s ability to thrive on adversity, receive gratification from work and generate health (Antonovsky, 1987b). As a paradigm, Antonovsky defines salutogenesis as the study of the strength individuals exhibit in order to manage the tension and stress in their lives and not succumb to illness (Onega, 1991). Strümpfer (1995) suggests that the term fortigenesis (from Latin: fortis = strength and Greek: genesis = origins) seems to be more descriptive of the field of salutogenesis, because the focus of salutogenesis is more on the enhancement of strength in the individual, rather than on why and how people stay well.

4 THE SALUTOGENIC MODEL The salutogenic model focuses on the origins of health and wellness and was developed as an answer to the salutogenic question (Antonovsky, 1987a, p. 47). This model was developed and presented by Antonovsky in his book, Health, stress and coping (Antonovsky, 1979). The main thrust of the salutogenic model is that stressors are omnipresent in human existence, and yet many people survive and even flourish under these difficult circumstances. Salutogenic thinking has since inspired much research into why some individuals cope successfully in spite of omnipresent stressors and others do not (see Antonovsky s salutogenic model of health in fig. 4.1). The salutogenic model is conceptualised as a cyclical process whereby an individual can feature anywhere at any point in time along a health ease/disease continuum in which health-ease is at the optimal end of the continuum and disease at the unfavourable end (Antonovsky, 1979, pp ). According to this model, an individual s position and direction of movement along the continuum are determined by the interplay of opposing forces of environmental threat (eg stressors), one s resistance (eg generalised resistance resources), and the strength of one s sense of coherence (SOC). Antonovsky s answer to the question of how some people manage to maintain psychological health, is expressed in the concept of generalised resistance resources (GRRs). GRRs form the basis of understanding the salutogenic model. According to Antonovsky, individuals develop GRRs through life experiences. GRRs refer to any characteristic of the individual, group, subculture or society that facilitates effective tension management (Antonovsky, 1979, p. 99). More complexly defined, a GRR is a physical, biochemical, artifactual-material, cognitive, emotional, valuative, attitudinal, interpersonal-relational, macrosociocultural characteristic of an individual, primary group, subculture, society that is effective in avoiding/combating a wide variety of stressors (Antonovsky, 1987b, p. 105).

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6 112 Antonovsky (1987b, p. 198) advances that the extent to which our lives provide us with GRRs is a major determinant of the extent to which we come to have a generalised, pervasive orientation that I call a strong sense of coherence. The fundamental property of a GRR is that it is a resource. It is something which in the possession of a group or individual, makes possible either the avoidance of stressors or the resolution of tension generated by stressors. The extent to which GRRs are available to one plays a decisive role in determining one s location and movement on the health ease/dis-ease continuum. Antonovsky (1979, p. 100) identifies the GRR concept to Selye s (1976) concept of resistance stage in his stress model (see chap. 2 for a discussion of Selye's stress model). Just as the GRR concept refers primarily to characteristics that facilitate dealing with and overcoming the stressor, so Selye (1976) highlights the actions directed at containing and offsetting the expressions of the alarm reaction, in order that the organism not enter the third stage of exhaustion. In the salutogenic model (see fig. 4.1), Antonovsky points to the relationship between stressors and movement toward the dis-ease end of the health ease/disease continuum. Stressors (physical stressors and psychosocial stressors) have an impact on GRRs. Unlike psychosocial stressors, whose impact is always mediated through GRRs and the sense of coherence, biochemical and physical stressors can be of such direct traumatic magnitude as to bypass interaction with the sense of coherence. These stressors (physical and biochemical) are, therefore, sufficient to overcome even substantial resistance resources. When, however, the standard of living in a society reaches a level of adequacy, when differences in health level no longer are overwhelmingly determined by biochemical and physical stressors, then psychosocial stressors and the SOC become crucial variables. Antonovsky (1987b) adds that at this point, salutogenesis becomes at least as intriguing and important a question as pathogenesis. The role of the SOC, as indicated in the salutogenic model (see fig. 4.1), is three directional (Antonovsky, 1987a). Firstly, by mobilising the GRRs as well as specific resistance resources (SRRs) available to an individual, a strong sense of

7 113 coherence can avoid one succumbing to some stressors. Secondly, it allows individuals to define some stimuli as welcome, which might otherwise be perceived as stressors to others. Thirdly, the sense of coherence operates decisively to what extent an individual will move on the health ease/dis-ease continuum. From the model, it is evident that salutogenesis is a cyclical process of life experiences functioning from the GRRs to strong salutogenic constructs which feed back to the GRRs which, depending on previous experiences of overcoming stressors, enhances the salutogenic construct or not. 4.4 SALUTOGENIC CONSTRUCTS This section is aimed at motivating for and discussing four different salutogenic constructs and the role they play in coping with stress and burnout in general and in the medical profession. Since Antonovsky s first public statement of the salutogenic orientation in 1973, numerous other personality constructs (besides Antonovsky s SOC) have been added to the salutogenic framework. It is important to point out that some of these constructs were developed prior to Antonovsky s sense of coherence theory, but are now being categorised for the first time under the umbrella term of salutogenesis (Strümpfer, 1990). Keeping with the aims of this study, it was deemed important to include some of these constructs which have come to be commonly known as the salutogenic constructs. In numerous reviews, the following independent constructs are identified as sharing common ground with the salutogenic model in their emphasis on successful coping and maintenance of or return to health. Strümpfer (1990, p. 265) reviews the following five constructs as sharing similar salutogenic properties: Antonovsky s (1979, 1987) sense of coherence, Kobasa s (1982a) hardiness, Ben Sira s (1985) potency, Thomas (1981) and Colerick s (1985) stamina and Rosenbaum s (1988) learned resourcefulness. In a different study, Parkes (1994) indicates five dimensions of personality that play a role in buffering the relationship between work stress and health outcomes: Rotter s locus of control,

8 114 Kobasa s hardiness, Matthews and Haynes type A behaviour, Eysenck and Eysenck s neuroticism and Scheier and Carvers s dispositional optimism. Later, Antonovsky (1979; 1987b; 1991) himself confirmed that these constructs formed part of the generalised personality orientation, which was studied in relation to successful coping and salutogenic outcomes. The confirmation of these studies mentioned above, motivated the incorporation of the following salutogenic constructs for the purpose of the empirical study: Antonovsky s sense of coherence, Kobasa s hardiness, Rosenbaum s learned resourcefulness and Rotter s locus of control. It is important to indicate that Strümpfer (1990, p. 265) considers the locus of control as a salutogenic related construct and not per say a construct that clearly falls within the salutogenic paradigm. The literature indicates that coping resources can be divided into internal and external resources (Kraft et al, 1993). In terms of salutogenic functioning, the internal or personal resources will be discussed as mechanisms of coping with stress and burnout in the medical profession. According to Kraft et al (1993, p. 341), personal resources include a list of personality constructs (most of which are salutogenic) and can be identified as bearing two core similarities: self control psychological sense (meaningfulness) From this theoretical understanding, it can be assumed that health protective behaviour corresponds with a person s beliefs and expectations; the maintenance of health lies within an individual s own hands, an individual can control his or her life and job conditions and can experience them as meaningful (Kraft et al, 1993, p. 341). What is common to all salutogenic constructs is their preoccupation with successful coping, and the studying of health instead of disease. The four constructs selected cover a range of personality characteristics and skills which research has proved to be linked to managing stress and keeping well (Antonovsky, 1991, p. 68; Strümpfer, 1990, p. 264; Sullivan, 1993, p. 1775).

9 115 Based on the above motivation for inclusion in this research, a discussion of the following four salutogenic constructs will serve as a background to the empirical study in chapter 5: Sense of coherence: Antonovsky (1979) Hardiness: Kobasa (1979) Locus of control: Rotter (1966) Learned resourcefulness: Rosenbaum (1988) Sense of coherence (Antonovsky) Antonovsky, puzzled and impressed by those individuals who defied the odds which would seem to predict poor health, hypothesised that a well developed sense of coherence was at the heart of this success (Johnson, 1992, p. 5). A sense of coherence (SOC) is defined, according to Antonovsky (1987b, p. 19), as a global orientation that expresses the extent to which one has a pervasive, enduring though dynamic feeling of confidence that the stimuli deriving from one s internal and external environments in the course of living are structured, predictable, and explicable; the resources are available to one to meet the demands posed by the stimuli; and these demands are challenges, worthy of investment and engagement. Three personality characteristics, namely, comprehensibility (making sense of the stimuli in the environment), manageability (coping with the stimuli with available resources) and meaningfulness (identifying emotionally with events), arise from the definition of SOC (Antonovsky, 1984). These three components form the key of the SOC. The SOC is a crucial variable in determining movement on the health ease/dis-ease continuum. Antonovsky (1983) cautions that the SOC should not be confused with a particular coping style, rather, a strong SOC enables the selection of the most appropriate coping strategy to deal with the stressor being confronted.

10 116 At certain points in time, particular experiences are known to affect a temporary and minor shift in one s sense of coherence. Such changes, however, occur around a stable location on the continuum. In this regard, Antonovsky (1983) advances that the SOC is shaped and tested, reinforced and modified not only in childhood but throughout one s life. A strong SOC, includes a solid capacity to judge and see reality and it is often taken to mean I am in control and associated with the concept of an internal locus of control (Antonovsky, 1979, p. 123). However having a strong sense of coherence is not necessarily praiseworthy, since Antonovsky (1987b, p. 157) cautions that a person with a strong sense of coherence is quite capable of being what many would consider as insensitive, unpleasant, inconsiderate and exploitative. Whilst not conclusive, Antonovsky (1987b, p. 163), reports that evidence does lend itself to indicate that a relationship exists between the sense of coherence and health. He groups five areas of studies and data that provide evidence for this relationship: social structural variables, cultural variables, psychological variables, situational variables and animal studies. According to Antonovsky (1979), given the nature of human existence, it is difficult to conceive any one being extremely high on the ease-continuum, as this would require an unimaginably stable world and an inconceivably unchanging internal and external environment. Only someone who is totally out of touch with reality could claim to have absolute sense of coherence otherwise called by Antonovsy, a fake sense of coherence With reference to figure 4.1, arrow A signifies life experiences which are said to be crucial in shaping a sense of coherence. Antonovsky (1987b) advances that though life experiences, individuals develop generalised resistance resources (GRRs), which he defines as any characteristic of the individual, group, subculture or society that facilitates avoiding or combating a wide variety of stressors. In essence, a GRR provides one with sets of meaningful, coherent life experiences. Examples of artifactual-material GRRs are money, shelter and food. Cognitive

11 117 GRRs include factors such as intelligence or knowledge. Interpersonal relation GRRs are factors such as social embeddedness and social support. Macro, socio, cultural GRRs are factors such as rituals and religions. In essence then, the development of an individual s SOC is made possible through the generalised resistance resources that help to make sense of the countless stimuli with which one is constantly bombarded (Antonovsky, 1979, p. 121). When the individual regularly experiences the availability of GRRs, a personality construct develops, which Antonovsy (1979) calls the sense of coherence. If a strong sense of coherence is to develop, an individual s experiences must not only be predictable but also rewarding (with some measure of frustration and punishment) (Sullivan 1993, p. 1774). Put simply, the outcome depends on the underload-overlaod balance. Antonovsky (1987b, p. 124), advocates that the SOC is explicitly and unequivocally a generalised, long-lasting way of seeing the world and one s life in it. It is perceptual with both cognitive and affective components, and forms a crucial element in the basic personality structure of an individual which is rooted in the particular sociocultural and historical period of one s life. The SOC develops as a single dimension of personality, consisting of three interwoven components: comprehensibility, manageability and meaningfulness (Antonovsky, 1991:93). Each of these components will be addressed in turn Comprehensibility The component of comprehensibility refers to the extent to which one perceives the stimuli that confronts him or her as making cognitive sense, as information that is ordered, consistent, structured, and clear, rather than as noise-chaotic, disordered, random, accidental, inexplicable (Antonovsky, 1987b, pp ). The main principle underlying the component of comprehensibility is that life events which come one s way are perceived as making cognitive sense (Strümpfer, 1990). The person who scores high on comprehensibility, will expect future events to be predictable, orderly and explicable. Although stimuli may not

12 118 be of a desirable nature, (eg accidents), these stimuli and its consequences are viewed as challenges and within one s coping capacity Manageability Manageability is defined as the extent to which an individual perceives that the resources at one s disposal are adequate to meet the demands posed by the various stimuli that bombard one (Antonovsky, 1984, p. 118). This component is characterised by good load balance. Resources at their disposal may refer to resources under the individual s own control or resources controlled by legitimate others, such as friends, colleagues, God, political affiliations, professional help anyone upon whom one can count on and trust. An individual who scores high on manageability will not feel that their life is out of control ; rather he or she will by his or her own resources or with the support of legitimate others feel that he or she is able to cope and will not grieve endlessly (Antonovsky, 1984). This element of manageability coincides with Kobasa s hardiness component of control, where the individual with a good sense of control is characterised as having the ability to exercise control over the pace of events (Kobasa, Maddi & Courington, 1981) Meaningfulness Zika and Chamberlain (1992, p. 144) report, in conjunction with other research, that a positive relationship exists between psychological wellbeing and meaning in life. According to Antonovsky (1984, p. 119), the meaningfulness component refers to the extent to which an individual feels that life makes sense emotionally, rather than cognitively. This component is a move away from the cognitive emphasis as indicated in the previous two components. The component of meaningfulness, within the sense of coherence, recognises that individuals play a role in determining their own destiny and daily experiences. Thus, people who score high on meaningfulness feel that life makes sense emotionally. Furthermore, problems faced are seen as challenges and are perceived as worthy of investing energy, commitment and engagement (Antonovsky, 1984). Initially, comprehensibility was considered by Antonovsky (1984) as the most crucial component of the SOC. This was later changed to recognise the

13 119 meaningfulness component as the most integral of the three components. For an individual with a meaningful life, the resultant commitment and caring provides an advantaged access to gaining understanding and resources. Comprehensibility follows in importance, since high manageability is contingent on understanding (Johnson, 1992, p. 16) Hardiness (Kobasa) The concept of personality hardiness is defined as a constellation of personality characteristics that function as a resistance resource in the encounter with stressful life events (Kobasa, Maddi, & Kahn, 1982, p. 169). Kobasa (1982) introduced this concept as a result of her search for the reason why some individuals do not succumb to illness under high levels of stress. The root of this construct is embedded in an existential theory of personality, based on the belief that individuals behave in characteristic ways by consciously recognising and acting on their environments (Manning, Williams & Wolfe, 1988, p. 205). Kobasa s (1979a) work on the hardiness construct, although developed independently, runs parallel to Antonovsky s conceptualisation of the sense of coherence construct. According to Maddi and Kobasa (1984) in Funk (1992, p. 335), hardiness is a general quality that emerges from rich varied, and rewarding childhood experiences, and this general quality manifests itself in feelings and behaviours that are characterised as commitment, control and challenge the three components of the hardiness construct. Kobasa (1979a) advocates that individuals who score high on hardiness, appraise events from an optimistic point of view and are rarely overwhelmed by stressful events. In addition, hardy individuals decisively transform situations into a less stressful form as opposed to avoidance or becoming overwhelmed by the stressor. In possessing these characteristics, a hardy person is able to remain healthy under stress. The following is a description of the three personality dispositions that make up the hardiness construct (Kobasa, 1982).

14 Commitment Commitment is defined as a belief in the truth, importance and value of what one is and what one is doing; also a tendency to involve oneself actively in many situations in life, for example, work, family, friendship and social organisations (Kobasa, 1982, p. 6). This concept seems to stem from Kobasa s allegiance to existential psychology, which sees the person as a biological, social, and psychological being whose primary task is the search for and establishment of meaning (Kobasa & Maddi, 1977, p. 399). The commitment disposition is expressed as a tendency to involve oneself in rather than alienate from whatever one is doing or confronted with. In other words, committed persons relationships to themselves and to the environment involve activeness and approach rather than passivity and avoidance. Individuals who score high on commitment tend to have a generalised sense of purpose and ability to find meaning in the circumstances and relationships they find themselves in. As far as action is concerned, the highly committed individual is sufficiently empowered to the self and the relationship to the social context, for such a person not to give up easily under pressure (Kobasa et al, 1982) Control The concept of control in the existentialist view of personality, was originally operationalised by Kobasa using Rotters s locus of control measure (Antonovsky, 1991, p. 89). According to Kobasa (1982, p. 7), this refers to a tendency to believe and act as if, by and large, one can influence the events of one s life through what one imagines, says and does, with an emphasis on personal responsibility. This does not imply the naive expectation of complete determination of events and outcomes, but rather implies the perception of oneself as having a definite influence through the exercise of imagination, knowledge, skill and choice. According to Kobasa et al (1982, p. 169), control affects individuals on two levels. Firstly, control enhances stress resistance on a perceptual level, by increasing the

15 121 likelihood that events will be experienced as a natural outgrowth of one s actions and, therefore, not as foreign, unexpected and overwhelming experiences. Secondly, control affects coping in that a sense of control leads to actions aimed at transforming events into something consistent with an ongoing life plan and is, therefore, seen as less threatening. Even if an event or situation is not under one s control, individual s high on control incorporate the event, through processes and actions, into broad, longer term plan and as such, the situation seems consistent with their view of life Challenge The concept of challenge seems to be most closely related to the spirit of existentialism in its search for meaning, the orientation to the future, the zest involved in confronting choices, the ever-becoming (Antonovsky, 1991, p. 89). Challenge is defined as an expectation that change, rather than stability is the norm in life and that change will present one with opportunities and incentives for personal development (Kobasa, 1982). Individuals who rate high on the challenge dimension, mitigate the stressfulness of events on the perceptual side by colouring events as stimulating rather than threatening. Kobasa et al (1982, p. 170), advocate that in coping behaviours, challenge will lead to attempts to transform oneself and thereby grow, rather than to conserve and protect, what one can of the former existence. Kobasa (1979b, p. 4) advances that individuals who feel positively about change are catalysts in their environment and are well practised in responding to the unexpected. Furthermore, challenge fosters a sense of openness and flexibility, and thus allows for effective appraisal of change and difficult life events.

16 Locus of control (Rotter) Locus of control (LOC) is probably the most-cited construct in psychology and is used most often in empirical studies (Antonovsky, 1991, p. 79; Hurrell & Murphy, 1991, p. 133). The construct of locus of control is conceptually rooted in Rotter s social learning theory (1954), which maintains that behaviour in a specific situation is a function of expectancy and reinforcement value (Rotter, 1966). Rotter and his colleagues at Ohio state university formulated the locus of control construct in an attempt to explaining the failure of people to respond in a predictable manner to reinforcement (Antonovsky, 1991). He (Rotter) believes that the control construct is a global characteristic, which is relatively stable over time and across situations. As a general principal, internal versus external control refers to the degree to which persons expect that a reinforcement or an outcome of their behaviour is contingent on their own behaviour or personal characteristics versus the degree to which persons expect that reinforcement or outcome is a function of chance, luck, or fate, is under the control of powerful others, or is simply unpredictable (Rotter, 1992; Lefcourt, 1966, p. 207). Internal locus of control has always been associated with positive coping. In this regard, internal locus of control was positively correlated with high self-efficacy (Antonovsky, 1991, p. 79), high learned resourcefulness (Rosenbaum, 1980, p. 119), and the control construct of Hardiness (Kobasa, 1982). However, Rotter (1975) in Antonovsky (1991, p. 79) cautions that one should by no means generalise that internals are the good guys. People according to Rotter (1966, p. 1) can be differentiated on the basis of their generalised expectancy concerning internal and external control of reinforcement. If an individual perceives reinforcement to be contingent on his own actions (ie has an internal orientation), then positive or negative reinforcement will strengthen or weaken the behaviour. If, on the other hand, the individual believes that reinforcement is externally controlled by chance, fate, or powerful others, then reinforcement will not strengthen or weaken the behaviour.

17 123 Antonovsky (1991, p. 78) analysed Rotter s locus of control along with other salutogenic constructs. In conclusion of his review, Antonovsky (1991), places the structural origins of an internal locus of control under four headings: internality as a reflection of the objective situation, internality and culture, the concept of powerful others, and responsible versus defensive internality. Each of these structural origins will now be addressed: Internality as a reflection of the objective situation In societies or situations such as concentration camps or poverty-stricken circumstances, the objective reality of peoples lives are such that their fate becomes largely determined by powerful others or by chance. These forces are beyond their control and even their comprehension. In these situations, individuals will accurately come to see the world, in term of their frame of reference, as externals. Antonovsky (1991) indicates that, dynamically over time, this outlook becomes a self-fulfilling prophecy as it is deemed more functional for survival to have externalised beliefs. On the other hand, high internality is fostered in atmospheres of autonomy and freedom for effective action Internality and culture Guarding against ethnocentrism, Rotter (1966), made reference to fatalistic cultures as engendering an external locus of control. Antonovsky (1991, p. 83) reiterates this by stating that internality is likely to be nurtured in social contexts in which there is indeed room, objectively, for the individual to affect his or her environment and fate. In certain cultures such as those that resort to magic, the inadequacy of knowledge or opportunity for control fosters a culture of externality The concept of powerful others At the outset, it is important to indicate the distinction between powerful others and authority. According to Levenson (1981, p. 15), powerful others refers to a belief that the outcome of circumstances is in the hands of those with power, who are at best uninterested in the individual s welfare (Antonovsky, 1991). On the other

18 124 hand, with regard to authority, it is believed that those in control have legitimate power and act in one s own interest. Based on this differentiating factor of legitimate versus illegitimate power, it cannot always be assumed that being under the control of powerful others engenders externality. There are, for example, some family structures, religions and health care settings which acknowledge that parents, god, or the doctor have special knowledge or authority, encouraging proactive behaviour (Antonovsky, 1991). Growing up or living in such sociocultural settings might well foster strong benevolent powerful other beliefs which correlate positively with internality Responsive versus defensive internality Firstly, negative experiences over which there is little control are conducive to the development of high beliefs in external control and low belief in internal control (Wallston, 1981 in Antonovsky, 1991). This, according to Antonovsky (1991, p. 85) raises an important question: Does internality facilitate coping with stressors because it means taking credit for good outcomes while rejecting blame for unfortunate ones (defence), or does it do so because it expresses a willingness to assume responsibility, whatever the outcome (control)? Internality could facilitate coping with stressors, because it means taking credit for good outcomes while rejecting blame for unfortunate ones (defence). Also, internality could be characterised by a willingness to assume responsibility whatever the outcome. On the other hand, in the absence of control over outcomes, externality could foster the development of self-blamers (Antonovsky, 1991). In addition, defensive internals are characterised by verbally giving external reasons for past failures but in the belief that own behaviour will determine outcomes (Rotter, 1992, p. 128) Learned resourcefulness (Rosenbaum) Rosenbaum (1988), inspired by the works of Meichenbaum (1977), developed the term learned resourcefulness. Meichenbaum believed in the effectiveness of coping skills training through self-regulation. He advocated that once clients

19 125 acquire coping skills, they change their perceptions of their condition from learned helplessness to learned resourcefulness (Meichenbaum, 1977; Rosenbaum & Jaffe, 1983, p. 216). This construct has its theoretical base in the field of behaviour therapy Learned resourcefulness as a personality repertoire The term learned resourcefulness refers to an acquired repertoire of behaviours and skills by which a person self-regulates internal events (such as emotions, pain, and cognitions) that interfere with the smooth execution of a target behaviour (Rosenbaum & Jaffe, 1983, p. 215). Learned resourcefulness is not a personality trait, but a personality repertoire which is a set of complex behaviours, cognitions and affects that are in constant interaction with the individual s physical and social environment and are evoked by many situations; they also provide the basis for further learning (Strümpfer, 1990, p. 273). In essence, learned resourcefulness then is a basic behavioural repertoire that is learned from birth and serves as a basis for coping with stressful situations (Staats, 1975 in Rosenbaum & Palmon, 1984, p. 245). According to Rosenbaum and Ben-Ari (1985, p. 200), the specific behavioural skill that constitute learned resourcefulness include use of cognitions and self-instruction to cope with emotional and physiological responses application of problem-solving strategies ability to delay immediate gratification general belief in one s ability to self-regulate internal events Learned resourcefulness as a self-controlled behaviour The above skills come into action when the individual is confronted with stressful events. According to Rosenbaum (1988), all coping with stressful events call for

20 126 attempts at self-regulation or self-control. It is for this reason, reports indicate, that subjects scoring high on the SCS are found to have an internal locus of control (Rosenbaum, 1980, p. 119). The process of self-regulation, according to Rosenbaum (1980), occurs in three phases: Representation phase: The individual experiences, without any conscious effort, a cognitive and/or emotional reaction to changes within himself or herself or the environment. Evaluation phase: The evaluation of the changes, first, as desirable or threatening, then, if threat is appraised, evaluation whether anything can be done about it. Action phase: Action is taken (or coping) to minimise the negative effects of the internal or external changes. Over time, individuals who succeed to self-regulate their internal responses acquire skill in doing so. The learned resourcefulness thus provides a basis for further learning and becomes a source of information for judgements or selfefficacy in coping (Rosenbaum, 1980). The individual who measures high on learned resourcefulness will be able to deal with stressors by means of problem-focused strategies. Negative thoughts and emotions are regulated, enabling the individual to persistently deal with the stressor, whilst delaying gratification of personal needs. This enhances selfefficacy, since the perception of the self as effective and efficient motivates the individual to persist with the task (Rosenbaum, 1988). On the other hand, the individual who measures low on learned resourcefulness is not goal-oriented or problem-focused in dealing with stressors. In this case, negative internal responses are not controlled, thus hindering persistence in dealing with the stressor. This inculcates reduced feelings of efficacy and leads to self-perceptions of inefficiency and helplessness. In addition, Rosenbaum (1989, p. 249) postulates that learned resourcefulness is necessary for both redressive self-control and reformative self-control. Redressive

21 127 self-control is aimed at resuming normal functions that have been disrupted, such as going to a dentist when you experience pain in a tooth. Reformative selfcontrol is directed at breaking habits in order to adopt new and more effective behaviours such as going to the dentist for a check up as a preventative measure. Rosenbaum (1988, p. 484) concludes that individuals high in learned resourcefulness use more self-control methods during a stressful encounter than low resourceful individuals. 4.5 COPING The following section attempts to present the key issues on coping as identified in the literature. Coping is crucial in the understanding of salutogenic functioning, which is essentially concerned with positive outcomes of the stress process. The section will concentrate on a transactional discussion of coping (see fig. 4.2) which is a continuation of the transactional theory of stress discussed in chapter 2. To conclude this section, the role that salutogenic constructs play as a coping mechanism in the face of stress and burnout, will be discussed individually Definition of coping The concept of coping is a crucial part of the overall view of stress, determining to a large extent the outcome of a stressful encounter (Lazarus & Folkman, 1984b). Most comprehensive models of stress view coping as a buffer factor (see fig. 4.2) that mediates the relationship between stressors and outcome, or between antecedent stressful events and negative outcomes (Endler & Parker, 1990b; Folkman et al, 1986, p. 571). According to Cox (1987) in Cooper and Payne (1991, p. 19), a transactional definition of coping is the cognitions and behaviours adopted by the individual, following the recognition of a stressful transaction, that are in some way designed to deal with that transaction. In the transactional model, coping includes cognitive and behavioural efforts to master, reduce or tolerate internal and external demands (Lazarus & Folkman, 1984b). This view is expressed in figure 4.2.

22 128 Theoretically, coping follows three stages: the primary appraisal, the secondary appraisal and lastly the coping stage (Lazarus & Folkman, 1984b). This third stage, called coping, is crucial in determining outcome of the stress-response interaction. Individual differences play a key role in the selection of coping option; these different coping options thus have implications for moderating the stressoutcome relationship. Coping has two major functions: dealing with the problem that is causing the distress (problem-focused coping) and regulating emotion (emotion-focused coping) (Lazarus & Folkman, 1984 cited in Dreary et al, 1996, p. 4). Reports indicate that people use both types of coping in virtually every type of stressful encounter, although there are marked individual differences in how people cope with stress (Cooper & Payne, 1991, p. 10). In terms of coping success, it is likely that people will cope better when they are able to access coping strategies which are comfortable and familiar. Furthermore, coping success depends on the degree of fit between preferred coping strategy and situational constraints (Carver, Scheier & Weintraub, 1989).

23 129 The transactional model of coping (Heim, 1991) is built on the transactional theory of coping of Lazarus and Folkman (1994) General themes in understanding coping The following is a look at five general approaches to coping. The first approach focuses on characteristics of the personality that are antecedents of coping (Kobasa, 1979; Wheaton, 1983). Wheaton (1983) considers fatalism and inflexibility, while Kobasa (1979) considers hardiness. According to Folkman et al (1986), the assumption underlying this approach is that personality characteristics dispose the person to cope in certain ways that either impair or facilitate the various components of adaptational status. However, there is little evidence that these personality characteristics do in fact significantly influence actual coping processes (Cohen 1984; Fleishman, 1984). The assumption underlying the second approach to coping is that the way in which a person copes with one or more stressful events is representative of the way he or she copes with stressful events in general (Moos & Billings, 1982; Folkman, et al, 1986, p. 571). This involves assessing the way in which a person actually copes with one or more stressful events. The third popular approach to coping, focuses on characteristics of the stressful situation that people experience. The assumption of this approach is that people who are repeatedly exposed to uncontrollable situations experience helplessness, become increasingly passive in their coping efforts, and ultimately experience demoralisation and depression (Krohne & Laux, 1982 cited in Folkman et al, 1986, p. 571). The fourth and most sophisticated approach to coping is illustrated in the works of Pearlin and Schooler (1978). According to Folkman et al (1986), this approach deals with the contribution of personality characteristics and coping to psychological outcome. This approach advocates that personality characteristics and coping responses have different effects that are relative to each other,

24 130 depending on the nature of the stressful conditions. Results, according to this school of thought, indicate that personality characteristics are more helpful to the stressed person in those areas in which there is little opportunity for control (eg at work), whereas coping responses are more helpful in areas in which the person s efforts could make a difference (eg in the context of marriage). Finally, the approach to coping to be accepted for the purposes of this research, draws from all the other approaches within a framework of cognitive theory of psychological stress and coping. Here coping reflects a dynamic, mutually reciprocal, bi-directional interplay between personal and environmental factors, and the appraisal and coping processes that occur within this context (Folkman et al, 1986) (see fig. 4.2). This approach is transactional and is rooted in the works of Lazarus and Folkman (1984b) Models of coping Understanding how coping may be related to outcomes has been approached from several perspectives. The following is a brief account of the development of coping models Psychoanalytic theory and ego psychology Freud (1955) in Moos and Billings (1982), believed that ego processes serve to resolve conflicts between an individual s impulses and constraints of external reality. The function of ego-processes is to reduce tension by enabling the individual to express sexual and aggressive impulses indirectly, without recognising their true intent. These ego processes are cognitive mechanisms, although they do have behavioural expression Lifecycle perspectives This perspective focuses on the gradual accumulation of personal coping resources over an individual s life span. The main assumption underlying this perspective is that adequate resolution of the transitions and crises that occur at

25 131 each point in the life cycle leads to coping resources that can help resolve subsequent crises (Moos & Billings, 1982, p. 213) Evolutionary theory and behaviour modification Darwin s evolutionary perspective on adaptation provided the basis for a behaviourally oriented counterpoint to the psychoanalytic concern with intrapsychic and cognitive factors (Moos & Billings, 1982). This orientation led to emphasis on behavioural problem-solving activities that contribute to individual and species survival. More recently, the cognitive oriented components have been included to the traditional focus of problem-solving behaviour, and has become known as cognitive behaviourism (Goldberger & Breznitz, 1982). Bandura and Adams (1977) advocate that individuals must believe that they can successfully accomplish a task in order for them to engage in active efforts to master that task Cultural and socioecological perspectives The perspective highlights an adaptation to the conditions of the physical and cultural environment, by the facilitation of cooperative efforts of the human community (Moos & Billings, 1982). The concept of environmental coping resources emerged from this perspective. An important aspect of this perspective is social networks, which can provide such interpersonal resources as emotional understanding, cognitive guidance and tangible support. Moos and Billings, (1982) point out that, according to this approach, environmental resources can affect the appraisal of the threat implied by an event, as well as the choice, sequence and relative effectiveness of coping responses An integrative conceptual framework (transactional model of coping) The elements identified by the four perspectives reviewed above, have been integrated in a framework that conceptualises the link between life stress and functioning (as mediated both by personal and environmental coping resources), and by cognitive appraisal and coping processes, as well as their

26 132 interrelationships. The transactional model of stress and coping has its roots in this perspective (Lazarus & Folkman, 1984). This conceptual model illustrates that life events, and the personal and environmental coping resources related to such events, can affect the appraisal reappraisal process, as well as the selection of coping responses and their effectiveness (Moos & Billings, 1982, p. 214). The following is a comprehensive description of the transactional model of coping (Lazarus & Folkman, 1987): a Coping strategies Once a situation is perceived as threatening, an individual appraises how dangerous or problematic it is and what kind of coping strategy he or she will need to use to reduce the potential harm to his or her mental and/or physical wellbeing (Dewe, 1992). i Problem-focused strategy Problem-focused strategy is concerned with directly confronting or dealing with the source of stress. It is characterised by solving the problem and seeking information and alternative rewards. This can be done in a cool, rational, deliberate manner or it can be done aggressively. ii Emotion-focused strategy Emotion focused coping is characterised by heightened negative emotional responses which interfere with effective problem solving. This type of coping includes distancing, self-controlling, seeking social support, escaping-avoiding, accepting responsibility, and positively reappraising. Note that emotion-focused coping involves purely cognitive activities that involve changing the meaning of stressful encounters. If the individual is successful, there is no reason to experience emotional distress, since the harmful or threatening relationship has been made subjectively benign (Lazarus & Folkman, 1984).

27 133 According to Lazarus and Folkman (cited in Moos & Billings, 1982), people who perceive an event as controllable should be able to mobilise more effective problem-focused coping responses and consequently may experience less emotional arousal and distress. Cognitive appraisal and coping are all transactional variables. Folkman et al (1986, p. 572) assert that neither of these variables refer to environment or the person alone, but rather to the integration of both in a given transaction. Recently, it has come to be recognised that there is no one best way to cope. Rather, a successful outcome is engineered by the individual fitting the right strategy to the situation (Cooper & Payne, 1991, p. 23). Furthermore, individual differences play a crucial role in which coping options an individual will employ; this decision is not confined to utilising a single strategy, but to utilising a combination of options an indication of the complexities surrounding personenvironment transactions. b Coping resources According to Heim (1991, p. 96), Manning, Williams and Wolfe (1988, p. 205), the coping process not only depends on situational factors such as the stressors themselves, but it is strongly influenced by the intrinsic or extrinsic resources of the person, mostly his or her personality assets, social networks, constitutional predispositions and economic status (see fig. 4.2). Coping resources are a complex set of personality, attitudinal and cognitive factors that provide the psychological context for coping (Moos & Billings, 1982, p. 215). Such resources are relatively stable dispositional characteristics that affect the coping process and are themselves affected by the cumulative outcome of that process. For the purpose of this study, the four salutogenic personality dispositions of sense of coherence, hardiness, locus of control and learned resourcefulness will be discussed.